QAPI Program Utilization_Manual

PERFORMANCE IMPROVEMENT MONITORING AND EVALUATION PLAN Department: Home Health Scope: Provide skilled services to patients requiring care and treatment of their disease processes, including instruction, monitoring, assessment and evaluation of their response to treatment modalities, in their place of residence. Date: Responsibility: Case Manager, Nurse Clinician, Physical, Occupation and Speech Therapists, Nurse Executive, Clinical Supervisors, PI Committee Priority Focus Area Performance Measures/Outcomes Related Functions Benchmark Goal Data Collection (Methodology) Integration and Collaboration Communication - All verbal/telephone orders and critical test results are read back for verification by the person taking the order; verification is documented - All home care staff and physicians use only the Agency approved list of abbreviations, acronyms and symbols when documenting Leadership Management of Information Provision of Care, Treatment and Service 100% Weekly review of in office patient records by a PI designee/Case Manager/Clinical Supervisor. Data will be aggregated, reviewed and reported on a monthly basis to the organization’s PI Committee, Director of Patient Care Services/Management Committee. Aggregate reports will be submitted to the Board of Directors and Professional Advisory Committee on a quarterly basis and summarized annually. All Clinical Staff (Employees and Contract) and Managers Risk Management Medical Director Referring Physician - Plans of treatment and verbal/telephone orders are reduced to writing and submitted to the physician within five (5) days of the start of care/receipt of the verbal/telephone order - Plans of treatment and verbal/telephone orders are returned to the office within thirty (30) days of the start of care date/receipt of the verbal/telephone order and contain the ordering physician’s original signature Leadership Management of Information Provision of Care, Treatment and Service 100% Data is collected from all in-office patient records by the Medical Records staff on a weekly basis and submitted to the Director of Patient Care Services/Management/ PI Committee on a monthly basis. Data will be aggregated, reviewed and reported to the Board of Directors and Professional Advisory Committee on a quarterly basis and summarized annually. Medical Records Department Data Entry Department Billing Department All Clinical Staff (Employees and Contract) and Managers Risk Management Medical Director 93